Original Articles.
Observations
THE MECHANISM OF THE NORMAL SPINE AND
ITS RELATION TO SCOLIOSIS.1
BT ROBERT W. LOVETT, M.D., BOSTON.
The present paper is an attempt to investigate
the normal movements of the human spine and
their relation to scoliosis. It is a carrying for-
ward of certain preliminary work already pub-
lished in which three points in spinal movements
were demonstrated and considered in their bear-
ing on scoliosis. These points were:
(1) Side bending and rotation of the spine are
parts of one compound movement and cannot
be disassociated. There are, therefore, only three
spinal movements, (a) flexion or forward bend-
ing; (b) extension or backward bending, and
(c) side-bending rotation.
(2) The rotation which accompanies side
bending varies widely in its type between side
bendings given in the flexed position of the spine
and side bendings in the hyperextended position.
(3) Every rotation movement of the spine
must be accompanied by side bending or lateral
curving of the spine.
In the present paper after a statement of the
conditions under which the work was done, there
will follow, (a) a description of each of the spinal
movements; (6) a description of the character-
istic movements in the cervical, dorsal and
lumbar regions, and (c) an application of these
facts to the question of scoliosis.
The study of scoliosis has been made almost
wholly from the pathological end. This method
has contributed to us a great amount of infor-
mation and has done much to clear up the subject,
but of late little progress has been made. It is
as if one undertook, for example, to investigate
a railroad accident solely from a study of the
wrecked cars. Much could be learned as to the
effect and direction of the destructive forces,
the amount of force expended, and the kind of
damage done, but more could be learned and
future accidents could be better prevented by a
study of the normal running time of the trains,
their proper relation to each other at the time
of the accident, and by an investigation of the
signal system and the routine precautions
adopted. In a similar way we have, I think,
much to learn from the normal spine that might
help our study of scoliosis. Its normal mobility,
its restrictions, and its weakest points of resis-
tance might all form part of our knowledge.
In an attempt to carry on my investigation
from the point mentioned the literature was
first looked into. The Weber Brothers, v. Meyer,
Volkmann, Hughes, Schulthess and others have
contributed to our knowledge, but nowhere can
be found an accurate, concise, clean-cut descrip-
tion of spinal movements. It, therefore, re-
mained to attack the question of normal spinal
movements and the same course as in the pre-
1Read by invitation before the Congress of the German
Association in Berlin, April 25, 1905.
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vious investigation was adopted.
were made the cadaver, these were checked
on
on a living model and on living children.
The anatomical work was done in the Anatomi-
cal Department of the Harvard Medical School
under the supervision of Prof. Thomas Dwight
to whom I am indebted for constant counsel and
help as well as for an abundant supply of anatomi-
cal material; and from Mr. Charles P. Heath,of
the second-year class of the Harvard Medical
School, I had the greatest help and the most
painstaking assistance throughout.
The material at my disposal was as follows :2
Cadaver 1 was a young male negro of twenty, in
an excellent state of preservation with a movable
spine. The viscera and thorax were intact,
except for a split in the sternum for injection.
This was later wired together. Cadaver 2 was
a female of twenty-three, also in good preserva-
tion, with a movable spine. The viscera were in
place and the sternum which had been split for
injection was wired firmly together. In this
cadaver the head, arms and legs were removed
at the outset and the pelvis imbedded in plaster
of Paris. The model was a professional female
model of twenty-two, markedly flexible and
symmetrical. I had at my disposal a clinic of
some two hundred cases of lateral curvature and
round shoulders in children from five to fifteen,
for permission to use which material I am in-
debted to my colleagues.
With regard to criticisms which apply to gen-
eralizing from what is seen in the cadaver to what
must happen in the living spine the following
facts were borne in mind: (1) The muscles are
absent so far as function goes. (2) The cadaver
is generally less flexible than the living subject.
(3) The drying of the tissues induces unnatural
limitations. (4) The constant manipulation may
loosen certain joints and distort motions. (5)
One obvious criticism applying to most work on
the cadaver has been avoided by doing most
of the work on cadavera intact, with the thoracic
and abdominal contents in situ.
In the analysis of the separate movements
of the spine, although careful measurements were
taken of each movement, the most reliable method
was found to consist in observation of the indi-
vidual pins which were driven into each spinous
process. Although at first it was my intention
to present a detailed analysis of spinal move-
ments, especially rotations, in figures, angles and
arcs, after taking many measurements I became
convinced that such figures would be of little
real value and that the time at my disposal would
be better expended on a study of the gross prop-
erties of the different regions and an analysis of
movements over a wider field of material, than
in an exhaustive analysis of the minute charac-
ters of the movements in one cadaver, for only
in the cadaver can accurate measurements be
made.
In the model, lead strip tracings and photo-
graphs were used and tracings of side curves
I2 The experiments on
Orthopedic Department of the Harvard Medical School.
the cadaver were
Much of the clinical
made in the Anatomical
work is from the Lateral Curvature Clinic of the Children's Hospital,
were taken on crinoline gauze laid over the back
through which the spinous processes were felt
and marked. The same methods were also
followed in the cadaver. The methods adopted
in the study of the different regions will be ex-
plained in discussing that part of the subject.
I. A Description op the Movements
Spine.
The spine as a whole. Investigation^ the
—
spine after the removal of the head, arms and
legs showed a practical point, namely, that the
human spine is not an extremely flexible body
taken by itself but that much of its apparent
flexibility is due to accessory movements between
the spine and the pelvis and the head. An
extreme forward flexion, e. g., in the living model
or the intact cadaver, with the flexed head, the
drooping shoulders and the rotated pelvis implies
a greater curve than the spine itself possesses.
It was surprising to see how little actual mobil-
ity was possessed by the three regions of the
spine considered separately, or by the whole
spine.
The application of this is obvious without
extended comment. If active or passive exer-
cises are given which are intended to take effect
upon the spine alone and to be effective there,
the pelvis must be fixed. If this is not done,
part of the muscular force is used in displacing
the pelvis to the opposite side to balance the
body, and the movement becomes a general and
not a spinal one. (Figs. 1 and 2.)
Flexion (forward bending) appears to be a
pure antero-posterior movement without per-
ceptible rotation.3 It is the most evenly dis-
tributed of the spinal movements, and in extreme
flexion the outline of the tips of the spinous
processes forms a curve approaching the arc of
a circle. Most of the movement is accomplished
in the lumbar region which in extreme flexion
loses most of its forward convexity, but in the
observations made was not observed to become
convex backwards. (Figs. 3, 4, 5.)
The dorsal region in extreme flexion becomes
decidely more convex than in the upright position.
The twelfth dorsal vertebra takes part in flexion
more as a lumbar than as a dorsal vertebra and
free movement occurs below it and fairly free
movement between the eleventh and twelfth
vertebras.
The cervical region cannot be accurately ob-
served or measured in the model. In the cadaver
it dried so rapidly while the other observations
were being made that no conclusions can be drawn
beyond the statement that its forward convexity
may be obliterated by forcible flexion with the
hands.
The most marked flexion of the spine was
obtained by having the model sit cross-legged
and bend forward with the chest between the
knees, and extreme passive flexion with the
model lying on the side was not so great as was
obtained by flexion in the cross-legged position.
3 De la Escoliosis. Saturnino Garcia y Hurtado,
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There seemed to be no constant difference in the
amount of flexion obtained in the standing and
sitting positions, the resultant curve being prac-
tically the same. The chief difference between
flexion in the model and cadaver seemed to con-
sist in a greater relative participation of the dorsal
region in flexion in the model.
of the It is noteworthy that measurements and
tracings of the spine in the model and in children
show the relaxed sitting position to be one of
slight flexion.
In the spine of cadaver 1, the laminae and
pedicles were removed and the column of bodies
was studied alone. The character and distribu-
tion of the flexion were not changed.
In flexion the distance of the seventh cervical ver-
tebra from the sacrum when measured along the spinous
processes is increased over the same measurement
taken in standing or lying. In cadaver 1, the distance
was 46 cm. lying flat and 52.5 cm. in full flexion.
In the model, the distance from the seventh cervical
vertebra to the fifth lumbar, measured over the spinous
processes, was, in the erect standing position, 43.5 cm.,
and in full flexion from the erect position 51 cm. These
figures show an increased length in the dorsal and
lumbar spines, measured along the spinous processes,
of 6.5 cm. in the cadaver, and 7.5 cm. in the model in
flexion over the erect or prone position.
Measurements of the spine in the model taken from
7th cervical vertebra to and including the 5th lumbar,
over the spinous processes were as follows:
Passive Movements.— Standing, erect, pelvis free,
43.5 cm.; extreme flexion, pelvis free, 51 cm.; exten-
sion, pelvis free, 38 cm.
Sitting, pelvis free, relaxed (that is, natural position),
46.5 cm.; extreme flexion, 51.5 cm.; extension, 38.5
cm.
Standing, pelvis fixed, erect, 44 cm. ; extreme exten-
sion, 37 cm.
Sitting, pelvis fixed, relaxed, 46 cm. ; extreme exten-
sion, 39.5 cm.
Active Movements. Standing, unsupported, pelvis
free, erect, 44 cm.; extreme extension, 41.5 cm.;
—
pelvis fixed, extreme extension, 40.5 cm.
Hyperextension (backward bending). —Hyper-
extension appears to be a pure antero-posterior
movement of the spine without perceptible rota-
tion. It is not an evenly-distributed movement,
but occurs almost wholly in the lumbar and lower
two dorsal vertebras. A tracing taken over the
spinous processes in extreme hyperextension in
outline resembles a hockey stick. The dorsal
region is but little affected, being slightly straight-
ened by hyperextension. The bending reaches
to about the tenth dorsal, the upper dorsal region
showing but little diminution in the physiological
curve, the twelfth dorsal vertebra, and, to a certain
extent, the eleventh, behaving as do the lumbar
vertebras in hyperextension. The curve taken
over the spinous processes was more marked in
cadaver 2, a female with a naturally arched back,
and in the model than in cadaver 1, a male with
a less marked lumbar physiological curve. The
character of the curve obtained in marked hyper-
extension was practically the same, whether it
was obtained by active or passive means and
Madrid, page 19. whether the model was lying on the face or on
the side, or standing, or sitting. The column of
bodies alone showed the same character and dis-
tribution of the movement as did the intact spine
of cadaver 1. The illustration in this case shows
the characteristic rigidity of the dorsal region
to hyperextension. (Figs. 6, 7, 8.)
In hyperextension, the distance from the
seventh cervical vertebra to the sacrum, meas-
ured over the spinous processes, is decreased
from the same measurement taken in the erect
position.
In cadaver 1, the distance from the seventh cervical
vertebra to the fifth lumbar in the prone position of
the body was 46 cm., and in hyperextension, 38.1 cm.
In the model measurements taken in the same way
with the pelvis fixed were 44 cm. for the erect position,
and 37 cm. in hyperextension. These figures repre-
sent a decrease in length of the dorsal and lumbar
spine, in hyperextension from the erect position, of 7.9
cm. in the cadaver, and in the model of 7 cm.
The entire shortening of the dorsal and lumbar spine,
measured over the spinous processes, from extreme
flexion to the hyperextended position, was, in cadaver
1,14.4 cm., and in the model, 14.5 cm.
From measurements taken of the model standing,
sitting, and with the pelvis fixed and free in both
positions, it was found that the amount of hyperex-
tension does not vary appreciably in these positions,
and that the extreme of the movement is not affected
by fixation or freedom of the pelvis. Active hyper-
extension in the model is much less free than the pas-
sive movement, in all positions; but the extreme of
active hyperextension again is not affected by fixation
or freedom of the pelvis.
Side bending. Although side bending is to
be considered as one part of a compound move-
—
ment of which twisting or rotation forms the
other part, for purposes of simplicity, the ele-
ment of side bending, that is, the side deviation
of the spine from the sagittal plane, will be con-
sidered by itself in this connection.
In describing this side bending it must be
stated that the character and distribution of the
movement vary widely according to the degree
of flexion or extension of the spine when the
side bending is made. It is also affected if the
spine is twisted before it is bent to the side. In
other words, there is no one type of spinal side
bending as there are types of flexion and exten-
sion, but the character and distribution of the
movements are wholly dependent upon the an-
tero-posterior position of the spine.
Side bending will first be considered alone
without regard to the rotation caused by it, and
then the rotation accompanying each kind of
side bending will be described.
Side bending in lying on the face shows a
more evenly distributed lateral curve than does
that in the erect position. The character of the
curve did not change essentially when the shoul-
ders and pelvis were held and the middle of the
trunk pushed to one side. The curve in this
position of the spine is greater in the upper lum-
bar vertebrae and in the two lower dorsal than in
the upper part of the spine.
Rotation accompanying side bending lying on
the face. With the cadaver lying flat on the
—
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face on the table no rotation in side bending was
found by v. Meyer and in some experiments by
Schulthess; it was, however, found by Benno
Schmidt.4 With the cadaver lying prone on a
table the conditions, of course, are against rota-
tion, the thorax and shoulders being to a certain
extent held against it by the surface of the table.
In cadavers 1 and 2 no perceptible rotation was
noted in slight side bending under these conditions,
but the vertebral bodies turned to the concave
side in marked side bending. In the model
lying flat on a table one side of the chest was felt
to press on the table harder than the other in
moderate side bending. The point is not of
great importance as the practical problem is that
of the behavior of the weight-bearing spine.
Side bending in the flexed position of the spine
is a more evenly distributed movement in which
the dorsal region participates more and the lum-
bar region less than in the erect position. The
greatest deviation from a line connecting the
two ends of the spine occurs at about the eighth
dorsal vertebra in both cadaver and model. In
short, side bending occurs higher in the spine
in flexion than in any other position, the lumbar
region being comparatively locked against side
bending by the flexed position. The more
marked the flexed position, the higher in the
spine is the side bending localized. (Figs. 9,
10.)
Rotation accompanying side bending in flexion.
In the flexed position of the spine, side bend-
ing is accompanied by rotation of the bodies to
—
the convexity of the lateral curve.5 This rota-
tion occurs chiefly in the dorsal region, the lum-
bar region seeming to be locked against side
bending by the flexed position. The so-called
flexion rotation which accompanied side bend-
ing described in my former papers is, therefore,
to be classed as a dorsal phenomenon, and might
perhaps better be spoken of as dorsal rotation.
The same phenomena were observed in the cada-
ver, the model and the child, and followed the
same rule observed in earlier experiments. One
practical point was noticed and confirmed in
the cadaver, viz., that rotation in this position
was less marked in the two cadavers with an
intact thorax than in those from which the ster-
num had been removed. Another point possibly
of practical importance is that in side bending
of the model in the flexed position the active
movement is accompanied by a much greater
degree of rotation than is the passive movement,
the addition of muscular force in this movement
seeming to accentuate the element of twisting.
The column of vertebral bodies alone from
cadaver 1 rotated in flexion side bending in the
same way as did the intact spine. (Fig. 11.)
Side bending in the erect position. This is, of
course, the most important aspect of the question
—
of side bending,so far as scoliosis is concerned.
In the cadaver the side bending is most marked
«Schulthess: Zeit. f. Orth. Chir., x, 3, p. 487.
5 R. W. Lovett: Mechanics of Lateral Curvature, Boston Medi-
cal and Surgical Journal, Oct. 31, 1901; June 14, 1900.
Mechanics of the Spine, Am. Journ. of Anatomy, ii, 4, 457.
Forcible Correction of Lateral Curvature, Boston Medical and
Surgical Journal, March 17, 1904.
 below the tenth dorsal vertebra, and the dorsal
region shares but slightly. The lumbar region
is most affected in its upper part, but shares to
some extent throughout. The whole dorsal
region takes some part in the movement, but the
dorsal region, except its lower part, compared to
the lumbar is resistant to side bending. Side
bending in the erect position is, therefore, largely
curve. In side bending occurring in the erect
or hyperextended position, however, the lumbar
region and lumbar dorsal region is the chief seat
of the movement, and as in all side bends in this
lumbar region the bodies of the vertebrae turn
to the concavity of the lateral curve.
Rotation. Rotation or twisting of the spine
is to be considered as part of a compound move-
—

a movement occurring in the neighborhood of
and below the lumbar dorsal junction.6 It shows
the same characteristics in the cadaver, the model
and the child, except that in the two last named
the dorsal region takes a greater relative part
than in the cadaver. (Figs. 12, 13.)
The column of vertebral bodies alone behaves
in side bending in all positions in the same way
as do the intact cadaver, the model and the child.
Rotation accompanying side bending in the erect
position. In this position side bending causes
the rotation of the bodies of the vertebrae to the
—
ment of which side bending forms the other part.
For purposes of simplicity the rotation element
of the movement will be considered by itself.
Under ordinary conditions it is essentially a move-
ment of the dorsal and cervical regions in which
the lumbar vertebrae take but little part except
in hyperextension and with the use of traction.
The lumbar vertebral region possesses some power
of rotation as has been generally observed.7
The measurement of this will be alluded to
later. Although many measurements were taken

of the amount of spinal rotation they cannot be

concave side of the lateral curve. It occurs regarded as of practical value as the amount of
lower down in the spine than in the flexed posi- twisting obtained varied with the degree of force
tion. The dorsal region participates less and used and the position of the cadaver.
the lumbar region more in the movement. Measurements of rotation in flexed and hyper-
Side bending in the hyperextended position of extended positions of the cadaver were so com-
the spine. With the spine of the cadaver, model plicated on account of the different planes in-
or child hyperextended, the side bending becomes
—

volved that they gave no trustworthy results.

a sharply limited movement, localized low down The observation of the pins and the photographic
in the spine and occurring almost wholly below method were, therefore, adopted, and the move-
the eleventh dorsal vertebra becoming, therefore, ment will be described in its general aspects.
essentially a lumbar movement. The dorsal Rotation in the erect position. Rotation is —

region bends as a whole upon the lumbar and
rocks over to the side practically unchanged
being locked against side-bending by the hyper-
extended position. Side bending, therefore, is
situated highest in the flexed position, lower
down in the erect position, and lowest in hyper-
extension in the model, cadaver and child. In
side bending in all positions the twelfth dorsal
vertebra behaves as a lumbar, not as a dorsal,
vertebra. (Figs. 14, 15.)
Rotation accompanying side bending in the
hyperextended position. This is a sharply limited
movement occurring in the lumbar region includ-
—
freest in the erect position and is situated in the
cervical and dorsal regions, reaching its maximum
at the top of the cervical column and extending
down the spine to the lower dorsal region where
it disappears. With very forcible rotation ap-
plied to the top of the column in the cadaver,
the first and even the second lumbar vertebrae
may be rotated. The rotation in this position
is accompanied by a side bend of the rotated
region away from the side to which the bodies
of the vertebrae turn. If the rotation is to the
right it is accompanied by a bend convex to the

left and vice versa. In the model an active rota-

ing the twelfth dorsal as functionally a lumbar
vertebra. The thorax rocks over to the side
unchanged and the rotation of the bodies is to
the concave side of the lateral curve. The
rotation accompanying this type of side bending
tion to the right is accompanied by a displace-
ment of the trunk to the left side and vice versa.
(Figs. 17, 18.)
Rotation with traction in the erect position.
If traction is applied to the head of the erect —

is essentially a different kind of motion from that cadaver, forcible twisting of the head results in
occurring in side bending in flexion as it is less rotation of the lumbar vertebrae including the
distributed through the spine and is of a more fourth. In cadaver 1 a rotation in the erect
decided character. The column of bodies alone position without traction made by moderate
rotates in essentially the same way as does the manual force resulted in rotation down to and
intact spine in side bending in the erect and including the eleventh dorsal vertebra. Trac-
hyperextended position. (Fig. 16.) tion of thirty-eight pounds was then applied to
Rotation accompanying side bending is, there- the head and approximately the same rotation
fore, of a different type in the flexed position force applied. The rotation was markedly in-
of the spine from what it is in the erect or hyper- creased and extended down further and included
extended position. In the flexed position the the fourth lumbar vertebra which rotated notice-
lumbar region is locked against side bending, and ably. In cadaver 1 with the spine erect, but
the side bend and rotation occur chiefly in the
7
Hughes: Archiv für Anatomie, etc.,
dorsal region and conform to the dorsal type, i. e., Archiv, 1892, p. 265.
für Anat. & Phys. 1827, p. 240.
the bodies turn to the convexity of the lateral Henke: Anat. und Meen, der Gelenke, Leipzig, 1863, 69.
Meyer: Statik, und Mech. des mench Knockengerüstes, 1873,
6 See
2, 12.
Lüning and Schulthess: Orth. Chir. München, 1901, p. Morris: Anat. of the Joints, London, 1879, p. 79.
132, fig. 51. I Volkmann: Virchow's Archiv, bd. 56, 1872, 4, 66.

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with no traction, rotation force was applied to
the head. While the head was held rotated
traction was applied. The spine lengthened
noticeably and the rotation extended well down
into the lumbar region. Lumbar rotation disap-
peared as traction was removed. In the intact
cadaver 1 with traction on the head the applica-
tion of a moderate rotation force to the top of
the column resulted in approximately 12° of
rotation of the first lumbar vertebra on the sacrum.
(Figs. 19, 20.)
Rotation of the flexed spine. Rotation in the
flexed position of the spine occurs chiefly in the
—
being those described above as cadavers 1 and 2.
In a third cadaver the lumbar region was fixed
by nailing the lumbar vertebrae together, and the
dorsal region was studied alone. In another
cadaver a detached thorax alone was studied
and photographed. In cadaver 1 a heavy brass
rod was thrust down through the vertebral canal
as far as the twelfth dorsal vertebra to stiffen
the dorsal region and the lumbar region was thus
studied alone. In cadaver 2 the three regions
were cut apart and studied separately. In the
model it was attempted to fix the thorax by a

steel brace consisting of two heavy uprights at

cervical and upper dorsal spine. The lower dor-
sal and lumbar region seeming locked against
rotating forces by the flexed position. The more
extreme the flexion the more markedly in cada-
ver, model and child is the rotation restricted to
the cervical and upper dorsal spine. In cadaver
1 and in the model, forcible rotation in marked
flexion seemed to be limited to the region above
and including the seventh or eighth dorsal ver-
tebrae. (Figs. 21, 22.)
Rotation of the hyperextended spine. In hyper-
extended positions rotation with moderate man-
the back reaching from the cervical region down
as far as the twelfth dorsal vertebra, two lighter
uprights on the side with crutches, a steel chest
piece, and a circular steel band embracing the
lower chest. This brace did not, of course,
rigidly fix the dorsal spine, but prevented free
movement.
the cervical region.
The observations in this region were unsatis-
factory because in the living model the region
cannot be studied, and in the cadaver it inevitably
—

dried while the other work was being done.

ual force occurs as a twisting of the whole thorax Flexion. It is possible to straighten the
on an axis in the dorso-lumbar region, the upper
anterior physiological curve, but in the dried
—

and mid-dorsal regions apparently being locked

against rotation by hyperextension. The site
of rotating movement in this position is, there-
fore, in the one of two vertebrae above and the
one or two vertebrae below the dorso-lumbar
junction.
specimen it was not possible to do more. Much
of the apparent forward flexion in the cervical
region in life is evidently due to the motion
between the occiput and the atlas.
Hyperextension. The physiological curve can
be increased to a certain extent. —

Rotation, therefore, is located high in flexed Side bending. Side bending is uniformly
positions, lower in erect positions, and is situated distributed throughout the cervical region and
—

lowest and is of a different type, being more is accompanied by rotation of the bodies of the
sharply localized, in hyperextended positions. vertebrae to the concavity of the lateral curve,
In the column of bodies alone rotation possesses
as in the lumbar region. Rotation and side
the same characters as does the intact column.
(Fig. 23.) bending seemed always associated.
Rotation. Rotation is extremely free between
Side bends accompanying rotation. A lateral the first and second cervical vertebrae, but for
—

deviation of the spine accompanies all rotations. —

the rest of the region it is limited. Rotation is

It is situated at the site of the rotation and is
convex to the right when the rotation is to the
accompanied by a side bend convex to the side
left and vice versa. In the erect position rotation opposite to which the bodies of the vertebrae turn,
that is, in a right rotation the curve is convex
causes a marked side curve in the dorsal region. to the left. The rotation of the first vertebra on
Combined positions. In the model and cada- the second was about 45° in cadaver 2. Although
ver, if a position of flexion is assumed and the
—

but little importance can be attached to these

body bent to the right, there will, of course, be observations on account of the drying of the
found associated with the left convex side curve region the mobility of the cervical region con-
a rotation of the vertebral bodies to the left, and sidered by itself is disappointing and less than
the left shoulder will be elevated. If now one had been expected from the study of the intact
attempts to see whether the rotation or side bend cadaver and the living model.
can be most easily overcome by passive manipu-
lation it will be found that the rotation cannot be DORSAL REGION.
corrected while the spine is bent to the right but The dorsal region is the least mobile part of
that the lateral curve can be straightened without the spine as a whole. The twelfth dorsal verte-
disturbing the rotation. The inference is that in bra from the point of view of function must be
a combination of side bending and rotation in regarded as a lumbar vertebra and not as part
flexion the rotation element is the more persistent. of the dorsal region.
Flexion. The dorsal spine already convex
II. The Characters op the Movements in the backward can be made somewhat more convex
—

Three Regions op the Spine.

by forward bending, but the extent of the move-
In attempts to study more carefully the char- ment is not great and by no means comparable
acter of the movements in the separate regions to the same movement in the lumbar region.
of the spine, four cadavers were utilized, two (Fig. 24.)

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 Measurements were taken by pins driven into each
dorsal spinous process in cadaver 2 as to the distribu-
tion of the flexion movement in the dorsal region.
These measurements were taken 10 cm. up from the
skin and before the dorsal region was separated from
the lumbar.
The extreme flexion length from 1st dorsal to 12th
dorsal, inclusive, 31.3 cm.
The extreme extension length from 1st dorsal to 12th
dorsal, inclusive, 27 cm.
The extreme flexion length from 1st dorsal to Hth
dorsal, inclusive, 27 cm.
The extreme extension length from 1st dorsal to
11th dorsal, inclusive, 26 cm.
The extreme flexion length from 2d dorsal to 11th
dorsal, inclusive, 23.5 cm.
The extreme extension length from 2d dorsal to 11th
dorsal, inclusive, 23 cm.
In a tracing of the spine of the model in the erect
position a line connecting the seventh cervical and
twelfth dorsal vertebrae was 36 cm. long, and a per-
pendicular erected on it measured to the point of the
greatest dorsal curve was 3 cm.; in extreme flexion,
the same line was 34.5 cm. and the perpendicular was
5 cm.
Hyperextension. Hyperextension is a motion
of very slight extent in the dorsal region. (Fig.
—
the lower end of the region. In a rotation of
moderate force in the upright position it extends
to and includes the seventh or eighth dorsal ver-
tebra. Rotation of this region is less in flexion
than in the erect position and does not extend
so far down. In hyperextension it is much
limited and in extreme hyperextension in the
cadaver the dorsal rotation movement seemed
to be obliterated.
Rotation is accompanied always by side bend-
ing, the lateral curve being convex to the side
away from which the bodies of the vertebrae
turn. In a rotation of the top of the column to
the left the lateral curve is to the right and vice
versa.
The practical points to be borne in mind in the
study of the dorsal region are the facts that rota-
tion is freer than side bending, that hyperexten-
sion is extremely limited, and that the rotation
of the vertebrae in side bending in the dorsal
region is always towards the convexity of the
lateral curve.
In the dorsal region of cadaver 2, separated from the
rest of the spine, the 12th dorsal being fixed in a vise,

the 1st dorsal could be made to rotate by the use of

25.) It consists of a diminution of the backward extreme force 55° to the right and 50° to the left.8 This
convexity and is most noticeable in the lower half observation was made by means of pins driven into
of the region. In the model, in extreme hyper- the spinous processes which were sighted on a protrac-
tor. This is not an observation of the rotation of the
extension, a tracing of the outline of the spinous dorsal region on the pelvis, but of the rotation of the
processes in the dorsal region made a straight dorsal region alone.
line. In tracings of the two cadavers in the The pelvis of cadaver 1 being fixed, and the spine
extreme hyperextended position, the backward held erect, a forcible rotation of the shoulders to the
convexity of the dorsal spine was never obliter- right was made. This affected only slightly the upper
ated. dorsal and cervical regions and is of interest on that
account as contrasted with rotations made by twisting
In cadaver 2 a tracing was taken of the dorsal region the head. The measurements in an observation of
and a line was drawn connecting the first and twelfth the latter manipulation were made by means of plumb
dorsal vertebras. This line measured in the erect lines dropped from the pins at a fixed point on to a
position 25.8 cm. The distance from this line to the protractor. They were as follows :
point of greatest backward curve was 1.4 cm. in Rotation in degrees.
this position. In extreme hyperextension the line was
24.2 cm. long and the upright distance was .8 cm. Sacral pin, 0
5th lumbar, 0
4th lumbar, 0
Side bending. bending of the dorsal
Side 3d lumbar, 4.5 to left
region is a fairly evenly distributed movement 2d lumbar, 8.5
—

of slight extent presenting an even curve which 1st lumbar, 11.5

is greatest in the mid-dorsal region. It is 12th dorsal, 17
11th dorsal, 21
freest in the erect position or lying on the face. 10th dorsal, 25
It occurs less markedly in flexed positions and 9th dorsal, 27
least in hyperextension. Side bending here is 8th dorsal, 34
7th dorsal, 40
always accompanied by rotation of the bodies of 6th dorsal, 43
the vertebrae to the convex side of the lateral 5th dorsal, 47
curve. With both ends of the dorsal region fixed 4th dorsal, 49.5
a lateral bend causes the same rotation. With 3d dorsal, 50
the upper end of the column free the rotation 2d dorsal, 50
1st dorsal, 51
occurring in flexion is very marked in cadavers 7th cervical, 54
from which the sternum has been removed.
In cadaver 2 with the twelfth dorsal vertebra LUMBAR REGION.
fixed in a vise with the thorax intact, the extreme Flexion in the lumbar region is a move-
lateral excursion of the first dorsal vertebra from ment of much freedom, but the physiological
side to side was 10 cm. with the use of moderate curve in the cadaver was not obliterated in
force. The vertical height of the dorsal region any case observed.
being 25.5 cm. this excursion represents an arc The excursion of the top of the column was noted in
of approximately 28°.
Rotation is the most marked of dorsal move- cadaver 2, the pelvis being fixed in plaster. The first
lumbar moved between the erect position and extreme
ments. It reaches its greatest extent in the 8
upper dorsal vertebrae and diminishes toward Compare measurements of Weber, Volkmann and Hughes. Loc.
cit.

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flexion 8.2 cm. The vertical height of the top of the In cadaver 2 with the dorsal spine removed and the
first lumbar from the first sacral vertebra being ap- pelvis embedded in plaster a total side excursion of the
proximately 9.5 ; this represented an excursion of first lumbar vertebra was 8.1 cm. with a vertical height
approximately 55°. of 9.5 cm. This represents an excursion of approxi-
In cadaver 2, the length of lumbar spine measured mately 50° to be contrasted with 28° of total side excur-
over the top of the spinous processes was 9.7 cm. in sion of the dorsal region.
the erect position and 12.5 cm. in extreme flexion,
showing a lengthening of 2.8 em. In the model, the Rotation in the lumbar region is extremely
length of the lumbar spine measured in like manner limited. It is diminished by extreme hyper-
was, in the erect standing position, 13.5 cm.; and in extension and is least or absent in extreme flexion.
extreme flexion, 17.5 cm., an increase in length of 4 Under natural conditions the rotation is greatest
cm. in the erect position, but by the addition of trac-
The excursion of pins driven into each lumbar
tion in that position it is decidedly increased.
spinous process was measured at a distance of 10 cm.
The lumbar region possesses marked mobility
up in the erect position and in extreme flexion. in flexion, hyperextension and side bending,
Excursion of the pin upward
from the erect position. and but little in rotation. Side bending is more
Sacral pin, 0.4 cm. free than rotation in contradistinction to the
5th lumbar, 4 „ relation of these two movements in the dorsal
4th lumbar, 6.5
3d lumbar, 7.8
„
region. The rotation which accompanies side
bending is also the opposite of that occurring in
„
2d lumbar, 9 „
1st lumbar, 9 „ the dorsal region. In the lumbar region the
bodies turn toward the concavity of the lateral
Hyperextension general spinal
as a movement
curve, i. e., in a bend convex to the left the
is essentially a lumbar motion and in that region bodies turn to the right. The lumbar region
is an evenly distributed bend.
must be considered in function as including the
In cadaver 2 with the pelvis fixed in plaster and the twelfth dorsal vertebra.
dorsal region removed, the first lumbar vertebra made
in hyperextension an excursion from the erect position In cadaver 2, with the dorsal spine removed and the
of 6 cm. with the use of marked manual force represent- pelvis fixed in plaster, the first lumbar vertebra was
ing an arc of about 40°. In flexion, it has been seen rotated with extreme manual force to the right and
that the excursion was 8.2 cm. from the erect position, left. The rotation of the first lumbar on the sacrum
the total excursion from front to back being 14.2 with was estimated by a protractor. Under these condi-
a vertical height of 9.5 cm. This represented a total tions, in the erect position an arc described by the pin
excursion of the first lumbar vertebra from extreme in first lumbar vertebra was approximately 15° to the
flexion to extreme extension of about 95°. right and 17° to the left.
The excursion of the individual pins was measured
as in flexion. The results were as follows: CERTAIN CONCLUSIONS AS TO THE MOVEMENTS OP
Excursion of each pin from THE THREE REGIONS OP THE SPINE.
the erect position.
Sacrum, 0.5 cm. 1.In the lumbar region flexion diminishes
5th lumbar, 2.5 „ mobility in the direction of side bending and rota-
4th lumbar, 2.9 „ tion, and extreme flexion seems to lock the lumbar
3d lumbar, 3.2
2d lumbar, 4
„
spine against these movements.
1st lumbar, 4.2
„
„
2. In the dorsal region hyperextension dimin-
ishes mobility in the direction of side bending and
In cadaver 2, the length of the lumbar spine erect rotation. Extreme hyperextension seems to
measured over the spinous processes was 9.5 cm., and
in the hyperextended position, 5.0 cm. In the model, lock the dorsal spine against these movements.
measurements taken in like manner gave the length 3. In flexion of the whole spine side bending
of the lumbar spine erect 13.5 cm., and in the hyper- is accompanied by rotation of the vertebral
extended position 11.5 cm. These figures show a de- bodies to the convexity of the lateral curve, the
crease in length of the lumbar spine measured over characteristic of the dorsal region.
the spinous processes of 4.5 cm. in the cadaver, and 4. In the erect position and in hyperextension
2 cm. in the model. In considering these figures, as of the whole spine side bending is accompanied
in all figures given for the model, it must be borne in
mind that such measurements on the living body are by rotation of the vertebral bodies to the concav-
necessarily relative, from the amount of error involved. ity of the lateral curve, the characteristic of the
lumbar region.
Side is a free movement in the lumbar
bending 5. The dorsal region rotates more easily than
region and forms in the erect position a very it bends to the side, whereas the lumbar region
evenly distributed curve. It varies markedly bends to the side more easily than it rotates.
in the flexed, erect and hyperextended positions. 6. Rotation in the dorsal region is accompanied
It is greatest in the erect position and least in by a lateral curve, the convexity of which is oppo-
extreme flexion. site to the side to which the bodies of the vertebrae
The rotation accompanying side bending in rotate.
the lumbar spine is always with the bodies turn- 7. The column of vertebral bodies obeys in
ing to the concavity of the lateral curve; in a flexion, hyperextension, side bending and rota-
bend convex to the left the vertebral bodies turn tion, and in the combinations of them the same
to the right. This is to be contrasted with the rules which govern the intact spine, a fact of
opposite rotation occurring in side bending in much significance in connection with the rotation
the dorsal region. theories of v. Meyer and Albert.

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III. Application of Spinal Movements
Scoliosis.
That certain of these anatomical facts
importance in connection with scoliosis is, I think,
unquestionable.
Sense of balance of the spine. The spinal
—
column is an upright weight-bearing column,
somewhat flexible in all directions, but in life it
must also be regarded as a column endowed with
a sense of equilibrium and balance by virtue of
its attached muscles which work in response to
central nervous impulses. If the pelvis of a cada-
ver is raised on the right side and the upright
spine is left free to move, the top of the column
falls to the left and the spine is curved convex
to the right. (Fig. 26.) This is the position
induced by gravity. If, on the other hand, the
right side of the pelvis of a living model or child
is raised and the upright spine is left free to move,
the top of the column remains upright and the
spine is curved in the opposite direction, convex
to the left. This is the position of balance over-
coming the position induced by gravity. (Fig.
27.) The sense of equilibrium has worked against
the force of gravity and has reversed the position
natural to the cadaver. (Fig. 28.) This instinc-
tive sense of balance and equilibrium must be
regarded as an attribute of the upright living
spine and must be given a place in our study of
scoliosis. It is effective in two directions:
1. The erect person always strives to keep the
head approximately over the middle of the pelvis,
that is, in the sagittal or antero posterior median
plane of the body.
2. The erect person always strives to keep the
shoulder girdle approximately in the same plane
as the pelvis, i. e., in the frontal or lateral plane
of the body.
To this adjustment, especially to the element
that seeks to keep the shoulder girdle in the same
plane as the pelvis, it seems to me too little atten-
tion has been paid in our studies of the mech-
anism of the production of scoliosis. In this
instinctive effort to keep the shoulders and head
as straight as possible to the front, while disturb-
ances twisting the column below are taking place,
is to be found, I think, an important factor in
explaining the fixed rotation of scoliosis. The
application of this study of spinal mechanics
should first be made to the condition known as
total scoliosis.
Total scoliosis is the name applied to those
single curves involving practically the whole
spine in one more or less uniform curve. As a
rule, the term is synonymous with postural
scoliosis and the condition is sometimes spoken
of as lateral curvature without rotation.
In the Lausanne school children investigation,9
comprising 2,314 school children, scoliosis with
a single curve was found in 91.4% of all curves.10
In 70% of all curves the scoliosis was one convex
to the left. Compound curves, i. e., double curves,
were found in 8.6% of all curves in this series.
9Scholder: Arch. f. Orth. Chir., i, 3, p. 327.
10G. M. Gould: Optic and Ocular Factors in Scol.
142, 562.
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to If passes to the kinds of curves seen
now one
patients coming for treatment one finds the
in
proportion of compound cases much larger.
are of Scholder's
Assuming figures to be representative,
they show compound curves in 44.5%, total
scoliosis in 20.8%, and other single curves in
34.7%. This marked diminution in the propor-
tion of cases of total scoliosis in older children
suggests that total scoliosis may change to a
compound form in its natural development.
This idea, advanced by Schildbach,11 has been
slightly touched on or hinted at by many writers.12
It has been observed to occur by Hess 13 in 26
out of 86 cases of total scoliosis observed over a
period varying from two weeks to eight and a
half years, the average being one and one-third
years. That total scoliosis may persist as such
over a certain period has also been demonstrated
by Hess, 60 out of 86 cases not changing to an-
other type while under observation for the time
mentioned above.
Experimental curves. Left total scoliosis of
the type seen clinically may be reproduced ex-
—
perimentally in the cadaver by raising the right
side of the pelvis and holding or suspending the
upper end of the spine approximately over the
middle of the pelvis. (Fig. 28.) It may also be
produced experimentally in the model or the child,
sitting or standing, by raising the right side of the
pelvis. (Fig. 27.) The characteristics of the ex-
perimental and clinical curves are the same, the
spine is curved convex to the left laterally and as a
matter of necessity the upper part of the spine is
twisted to the right so that the right part of the
shoulder girdle is twisted back in its relation to
the pelvis and the left side twisted forward.
This twist of the shoulder girdle is the inevitable
result of lateral curve to the left in a normal
a
living spine where the upper end of the spine is
free.
Torsion in total scoliosis. We have seen that
every lateral curve must be accompanied by
—
twisting, that the chief lateral flexibility is situ-
ated in the lumbar and lumbar dorsal region
and that lateral bending in this region is accom-
panied by twisting of the bodies of the vertebrae
toward the concavity of the lateral curve. In a
left convex curve, therefore, the upper spine and
thorax must twist backward on the right side, and
the phenomenon known as concave-sided torsion,
reverse rotation, retrotorsion, etc.,14 is seen as a
backward prominence of the back on the concave
side of the lateral curve, in standing and often
in bending forward.
If one looks down on a child with a left total
scoliosis, standing at ease, one sees that the shoul-
der girdle is held twisted backward on the right
in its relation to the pelvis. (Fig. 29.) These
torsion appearances are more marked in children
with a marked lumbar (lordosis) curve than in
those with round backs as pointed out by Schul-
thess.15 This is because the more the lumbar
»Schildbach: Die Skoliose, Leipzig, 1872.
12 Hoffa: Orth. Chir., 5th ed., 1905.
13 Hess: Zeit. f. Orth.
Chir., vi, 3, 4, 556.
14 Schultheis: Zeit. f. Chir.,
x, p. 489.
Am. Med, ix, « Zeit. f. Orth.
Chir., vi, 399, vi, 556, 1892, 1. Revue d'ortho-
pédie, vol. vi.
THE MECHANISM OF TUB NORMAL SPINE.—-LOVETT

Fío. 1.—Composite photograph (two exposures]on

the same plate) showing the model standing erect, and Fig. 2. Composite photograph of the model standing erect }
bending to the right without fixation of the pelvis. and bending to the right with the pelvis fixed. The movement
—

The movement is a general one. is limited to the spine.

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 Fío. 5-—Flexion of the spine in the column of vertebral
Fig. 3. Klexion of the spine in the model. bodies alone. The spine is that of cadaver I.
—

Fig. 6. Hyperextension in the model. The head is supported to secure

Fig. 4. —
Flexion of the spine'in'cadaver I. steadiness. — (See Fig. 7.)

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 Fío. 9. Side bending to the right in the flexed position of the spine
in the model. A lateral curve convex to the left is formed and the
—

vertebral bodies have turned to the left as shown by the elevation of the
Fig. 7. Hyperextension in the cadaver. left side of the back. (See Figs. 10 and 11.)
—

Fig. 10. Side bending to the right in the

flexed position of the spine in the cadaver.
—

Fío. 8. Hyperextension in the column of A curve convex to the left is formed and Fig. 11. Side bending to the right in for-
vertebral bodies alone.
— the vertebral bodies turn to the left. ward flexion in the column of vertebral bodies
—

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 Fig. 14.— Side bending to the right in the hyperextended
position of the spine in the cadaver. The movement occurs
junction, and the bodies
chiefly at and below the dorso-lumbar shown
Fig. 12. Side bending in the upright position of the model. The move- of the vertebra1 turn to the right as by the pins. The
ment is chiefly located at the dorso-lumbar junction. 3
—
lateral curve is convex to the left.

Fig. 13. Side bending in the upright position of the cadaver, Fig. 15. Side bending to the right in the hyperextended position of the
showing the same
— characteristics as Fig. 12. spine in the model. The head is supported to secure steadiness. (See Fig. 14.
—

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 Fig. 16. Side bending to the right in hyperex-
tension in the column of vertebral bodies. The same
—

characteristics are shown as in the previous figure.

Fig. 18.—Rotation of the column of

vertebral bodies, face to the left, by
moderate manual force. The picture is
the reverse of that in the model, but
shows the same characteristics.

Fig. 19. Rotation in the cadaver, face to the

left, by moderate manual force. The rotation
—

Fig. 17. Rotation of the model, face to the right, causing a dorsal does not affect the lumbar region ; no traction is
¡^ lateral curve convex to the left and a displacement of the trunk to the left.
— used. (See Fig. 20.)

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 Fig. 21. Rotation of the spine of the
cadaver, face to the right in the flexed posi-
—

Fig. 20. Rotation in the cadaver, face to the left, by tion of the spine.
moderate manual force, while traction of thirty-eight pounds
—
The movement is seen to be located in the
is made on the head. With the use of approximately upper part of the column by the deviation
the same force as in Fig. 19 the rotation involved the of the pins.
lumbar vertebrœ.

Fig. 23. Rotation of the spine of the cadaver,

Fig. 22. Rotation, face to the right, in the model in the face to the right, in the hyperextended j position.
flexed position of the spine. The rotation is located chiefly
—

The movement is seen to occur in the lower part of

in the upper dorsal region. (See Fig. 21.) the spine by the rotation of the pins.

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 Fio. 24. Extreme passive flexion ot the dorsal
spine. The spine has slipped somewhat in the vise as
—

shown by the inclination of4the lowest pin compared Fig. 26. The right side of the pelvis of the cadaver is raised and
with the same pin in Fig. 25; the apparent amount the upper part of the spine falls to the left, making a lateral curve
—

of flexion is therefore exaggerated. convex to the right.

Fig. 25. Extreme hyperextension by the use of

passive force—
in the dorsal region.

Fig. 27.—The right side of the pelvis of the model is

raised and the upper part of the spine is carried to the
right, making a lateral curve convex to the left.

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 Fig. 28.—The upper end of the spine of the
cadaver is held by the hand over the middle of the Fig. 30. —Experimental ^double £curve^¿{right
pelvis, while the right side of the pelvis is raised, dorsal, left lumbar) produced in the cadaver by
and position like that of the living model is pro-
a elevating the right side of the pelvis and twisting
duced with a lateral curve convex to the left. the upper end of the spine, face to the left.

Fia. 29. Boy with left total scoliosis photographed

from overhead, showing the carrying back of the
—

shoulder girdle on the right.

The front edge of the board on the floor^marks the
lateral plane of the pelvis.

Fig. 31.'—^Experimental! double curve (right dorsal, left lum- ¿

bar) produced in the model by elevating the right side of the pelvis j¿
and having the model actively twist the upper spine, face to the left.
"

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region is curved forward, the more markedly
will the torsion phenomena peculiar to that
region appear.
My own observations as to this twist of the
shoulder girdle are confirmed by the results of
Hess who found twisting back of the left shoulder
in only one out of twenty-eight cases of left total
scoliosis examined. From the fact that total
scoliosis can be produced experimentally, it may
be regarded as a malposition which can be pro-
duced by the normal mechanism of the spine rather
than as a pathological malposition of the spine
and that its clinical characteristics are the inevi-
table result of a force causing the spine to be
curved convex to the left.
A left total scoliosis may be cured, it may per-
sist as such, or it may change to another type of
curve.
It may be of use to apply our knowledge of
spinal mechanics to the prediction of what changes
are likely to occur to modify total scoliosis and
cause it to assume a compound type. If total
scoliosis tends to increase, it must do so by an
increase of the existing side bend and of the
existing twist since both are correlated, not
necessarily of both in exact proportion, but to
some extent both factors must share in it. The
shoulder girdle will, therefore, be more twisted
as the lateral curve increases. One, however, does
not see the condition clinically of extreme left
total curve and extreme right backward rotation of
the shoulder girdle except, possibly, in cicatricial
or paralytic cases. An adjustment apparently
takes place when the tendency of the total curve
to increase passes beyond a certain point. For
the explanation of this one naturally looks
to the instinctive tendency to equilibrium and
balance spoken of as an intrinsic property of the
upright living spine. There must be going on
at all times this effort to square the shoulder
girdle with thepelvis and to keep the head and
upper spine as nearly as possible in the median
line of the body. This adjustment will naturally
occur where the spine offers the least resistance
to it, and as individual vertebral columns vary,
the compensatory adjustment will take various
forms.
Double curves. Assume that a child stands
and sits with a left total curve. He will, after
—
a certain point in the deformity is reached, be
continually striving to twist the upper part of
his spine and his shoulder girdle forward on the
right and to bend the upper part of his spine
convex to the right to restore his balance. We
have seen that the dorsal spine twists more easily
than it bends to the side. He is, therefore, more
likely to twist his dorsal spine than to bend it
to the side. He will, therefore, twist the upper
dorsal spine to the left which twist, as we have
seen, necessarily carries with it a dorsal lateral
curve convex to the right.
If this theory of instinctive adjustment can be
accepted, the tendency to correct the twist of
the shoulder and upper end of the spine is suffi-
cient to explain the transition of a left total
curve to a right dorsal left lumbar curve. Such
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a doublecurve can be reproduced experimen-
tally in the cadaver (Fig. 30), the model (Fig. 31)
and the child by inducing a left total curve and
adding a twist, active or passive, of the shoulder
girdle forward on the right. A right dorsal left
lumbar lateral curve then exists.
Support is given to this idea by the fact that
in structural right dorsal left lumbar curves with
bony rotation one is likely to find in looking down
upon the standing patient that the left side of the
shoulder girdle is seen to be carried backward
in its relation to the pelvis and the right side
forward. This, of course, is the reversed position
to that seen in the left total curve. The same
relation of the shoulder girdle is to be noticed
in single curves to the left which are accompanied
by bony rotation, the position again being the
reverse of that seen in left total scoliosis.
A significant fact is contained in a statement
of Hess relative to this study of total scoliosis :
Wir dürfen aus diesen Zusammenstellungen den
Schluss ziehen, dass die Formen mit concav seitiger
Torsion und gleichmässigen Torsionsverhältnissen
nicht bloss als Totalskoliosen persisten sondern
auch ihre Torsion möglichst beibehalten.
This suggests that the disappearance of con-
cave-sided torsion in any part of the spine indi-
cates that the compensatory change has already
begun and that the so-called total scoliosis has
begun on its transition to a compound curve.
This part of the subject is of so great impor-
tance that I do not venture to enter on it here
without extensive clinical observation. This
question offers a promising field for future inves-
tigation in the application of spinal mechanics
to clinical conditions.
We should, therefore, regard with suspicion
any of apparent total scoliosis that shows
case
any departure from the clinical type described.
Such cases must be regarded as probably having
entered on the stage of transition.
That left total curves most frequently change
to right dorsal left lumbar compound curves
than to any other form is shown by the figures
of Hess and by a statement of Schulthess.18 But
we cannot expect the same final curves always
to result from the same initial curve. Various
forms of curves may occur from the same simple
curve. For example, the dorsal region may not
react as described and the dorsal and lumbar
region may yield, as a whole, to the left, later
The
showing bony rotation on the left side. as
spine has yielded backward and to the left a
whole and other types of compound curves may
obviously result from the same initial curve.
Up to the point of the occurrence of bony con-
vex-sided rotation the attitudes are, I think, to
be regarded as rather malpositions within the
range of the normal mechanism than as patho-
logical in type.
With the occurrence of persistent bony rota-
tion on the convex side of the lateral curve, it
must be assumed that pathological changes have
begun and that the normal mechanism does not
account for this phenomenon. The normal
i«
Lüning und Sehulthess: Orth. Chir., 1901, p. 248.
mechanism is capable of putting the spine into a
distorted position with curves in opposite direc-
tions, but not of causing bony rotation on the con-
vex side of the lateral curve.
The occurrence of such bony rotation must
be regarded as a superadded pathological change
tion on the left, in curves convex to the left and
vice versa). These represent the cases accom-
panied by pathological changes in the vertebrae,
Finally transition cases are to be recognized.
Summary. No summary is possible of a
paper which in its entirety is only a summing up
—

in structure due to abnormal plasticity of bone
in the affected individual.
Up to the point of bony rotation one must
remember that the phenomena can be experi-
mentally reproduced in any normal cadaver,
model or child, but that bony rotation cannot
be experimentally reproduced and cannot be
explained in terms of spinal movements.
I would, therefore, ask you to regard concave-
sided rotation as in a measure physiological and
convex-sided rotation as pathological, not that
the two phenomena are sharply separated, for,
of course, they run into each other and overlap,
but for purposes of greater clearness the types of
the two should, I think, be kept separate.
Bony rotation. The question of the cause of
bony rotation lies outside of my present line of
—
of certain facts in a field of study large enough
to fill a volume. The points that I have tried to
establish from anatomical and clinical data are
that total postural scoliosis is to be regarded as
as within physiological limits and that it can be
accounted for by the normal mechanism of the
spine; that the same normal mechanism will
account for the production of compound curves
from simple ones, but that it will not account
for the occurrence of bony rotation on the convex
side of the lateral curve which must be regarded
as a superadded pathological change. Certain
of the anatomical facts considered should be of
direct use in making more exact the gymnastic
treatment of slight scoliosis, but that they can be
carried over into the gymnastic treatment of struc-
tural scoliosis without very careful consideration

inquiry, and has been amply treated by German
writers.17 It seems to me to be explained by
the fact that the vertebrae of some children are
plastic and ready to be distorted by increased
pressure on one side and diminished pressure on
the other, and that Wullstein's experiments on the
dogs have proved this, if we need proof. In a
column curved to one side or to both sides in
different portions the pressure is greatest on the
side of the vertebra next to the concavity of the
curve and least on the side of the convexity,
because the line of weight falls to the median
side of the concavity. If the vertebra are plastic,
they will yield in the line of least resistance; that
is, toward the side of the convexity of the lateral
curve.
A plastic weight bearing column curved in two
directions will not yield straight to the side, but
in each case does not seem to me likely. In the
latter case we are no longer dealing with a spine
distorted by the normal mechanism, but by a
malposition to which is added a distorting path-
ologic process. That a knowledge of spinal
mechanics will make clearer the treatment of
structural scoliosis I have no question, but the
application 01 this knowledge will require further
study and careful investigation.
FIRST OF A SERIES OF ARTICLES ON THE
APPENDIX VERMIFORMIS.
BY WM. A. BROOKS, JR., A.M., M.D., BOSTON,
Assistant Surgeon, Massachusetts General Hospital.
Position. In tracing the development of the
human embryo, the appendix vermiformis is —

will also twist. The vertebral column in all first seen immediately following the differentia-
parts is curved in the anteroposterior plane tion of the large and small intestine. It is then
by the physiological curves. The rotation will found high up on the right side of the abdomen,
naturally be away from the line of gravity, the close to the liver.
median line of the column, because to twist As the ascending colon develops and obtains
toward it would be to encounter the greatest its growth downwards, the cecum with the appen-
instead of the least resistance. It seems to me, dix occupies a lower and lower position on the
therefore, wholly in accord with what we know right side of the abdomen, until, with the full
of general mechanics that in a plastic weight- development, the cecum and its appendix come
bearing column curved in two planes bony rota- to rest in the right iliac fossa, and it is here that
tion must occur on the convex side of each lateral the appendix is found in a great majority of cases.
curve. Frequently only the base of the appendix rests
Classification. From this point of view, there in the right iliac fossa, while the remainder lies
are then two distinct divisions of lateral curvature, towards the median line or hangs over into the
—

one, the total curves accompanied by promi- true pelvis.

nence of the back on the concave side of the The longitudinal bands on the ascending colon
—

lateral curve (rotation on the right, in curves and cecum invariably lead downwards to the base
convex to the left) which are to be regarded as of the appendix.
postural and not accompanied by extensive With the fastening back of the ascending colon
pathological changes. owing to the gluing together of the posterior
The other, the compound or more rarely, visceral layer covering the ascending colon and
single curves accompanied by prominence of the its mesentery and the parietal peritoneum lining
back on the convex side of the lateral curve (rota- the posterior wall of the abdominal cavity, the
17
Riedinger: Morph. und Mech. d. Skol., Wiesbaden, 1901. cecum and its appendix are practically held in
Schanz: Die Beiast. Def. d. Wirkelsäule, Stuttgart, 1904.
Hoffa: Orth. Chir., 5th ed., p. 328. one position, and the excursions of the appendix

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